Chasing Zero Infections Coaching Call Don’t Be Resistant: Reducing MRSA and Other Multi-Drug Resistant Organisms May 8, 2018
Agenda Welcome & FHA Mission to Care HIIN Trends and • Progress: HIIN Overview, Hospital-onset MRSA Bacteremia and the Up Campaign – Cheryl Love, RN, BSN, BS-HCA, MBA, LHRM, CPHRM, Director of Quality and Patient Safety and Improvement Advisor, FHA • Coaching Call: Reducing MRSA and other Multi-Drug Resistant Organisms – Linda R. Greene, RN, MPS, CIC, FAPIC, Manager of Infection Prevention, UR Highland Hospital, Rochester, NY Upcoming HIIN Events and Opportunities • Evaluation & Continuing Nursing Education •
HIIN Core Topics – Aim is 20% reduction • Adverse Drug Events (ADE) • Catheter-associated Urinary Tract Infections (CAUTI) Clostridium Difficile Infection (CDI) • • Central line-associated Blood Stream Infections (CLABSI) • Hospital-onset MRSA Bacteremia • Injuries from Falls and Immobility • Pressure Ulcers (PrU) Sepsis • • Surgical Site Infections (SSI) • Venous Thromboembolisms (VTE) • Ventilator Associated Events (VAE ) • Readmissions (12% reduction) Worker Safety •
Hospital-onset MRSA 0.10 0.09 0.08 0.07 Rate per 1,000 0.06 0.05 0.04 0.03 0.02 0.01 0.00 BL O-16 N-16 D-16 J-17 F-17 M-17 A-17 M-17 J-17 J-17 A-17 S-17 O-17 N-17 D-17 J-18 F-18 FL Rate 0.07 0.06 0.06 0.07 0.05 0.07 0.06 0.06 0.07 0.07 0.08 0.08 0.08 0.07 0.05 0.06 0.08 0.06 HRET HIIN Rate 0.06 0.06 0.06 0.06 0.05 0.06 0.06 0.05 0.06 0.05 0.06 0.05 0.05 0.06 0.05 0.06 0.06 0.06 # FL Reporting 89 89 89 89 88 88 88 87 89 89 89 89 89 89 89 88 85 85 #HRET HIIN Reporting 1,431 1,553 1,551 1,561 1,575 1,574 1,576 1,566 1,567 1,570 1,568 1,561 1,557 1,539 1,511 1,502 1,361 1,275 Source: HRET Comprehensive Data System, May 7, 2018
MRSA
MRSA and MDRO Resources, Trainings and Tools Online Resources: MDRO Change Package MDRO Checklist SOAP UP Resources Watch Past Webinars HRET HIIN Resource Library Guides Case Studies http://www.fha.org/health-care-issues/quality-and-safety/mtc-hiin.aspx and http://www.hret-hiin.org
Raise your game: The UP Campaign Cross cutting set of practices to better engage front-line staff without creating additional burdens
HAND HYGIENE reduces harm in SEVEN focus areas CDI SSI VAE CLABSI Sepsis MDRO CAUTI S O A P - U P http://www.fha.org/soapup
PROGRESSIVE MOBILITY reduces harm in EIGHT focus areas Worker Falls PrU VAE VTE Delirium CAUTI Readmissions Safety G E T - U P http://www.fha.org/getup
SEDATION MANAGEMENT reduces harm in SEVEN focus areas Failure Airway ADE to Delirium Falls VTE VAE Safety Rescue W A K E - U P http://www.fha.org/wakeup
ONGOING EVALUATION OF MEDICATIONS reduces harm in TEN focus areas ADE Falls CDI CAUTI SSI VAE CLABSI Sepsis MDRO Readmissions S C R I P T - U P
MDRO’s Linda R. Greene, RN, MPS,CIC, FAPIC Manager, Infection Prevention UR Highland Hospital Rochester, NY linda_greene@urmc.rochester.edu
Polling Question 1 What is your background? 1. Infection Preventionist 2. Quality 3. Nurse 4. Other
Definitions Colonization Growth and Multiplication without Disease Infection Clinical or subclinical response
MRSA Staphylococcus aureus Microbiology – Gr+ cocci with many virulent factors Frequent nosocomial- and community-acquired pathogen Mode of transmission – contact Clinical manifestations: • Skin and soft tissue infections • Pneumonia • Osteomyelitis / Arthritis • Bacteremia / Sepsis • Endocarditis • Toxin-mediated disease
Year: 1950’s
History of MRSA
A cure all for staph ?
Where does MRSA reside? Epidemiologic niche: • Nasal carriage (anterior nares) • GI tract (rectal) • Perineal • Throat Nasal carriage – 30% of adults • 20% Persistent carriers • 60% Transient carriers • 20% Never carriers Nosocomial transmission – transient hand carriage
How does resistance develop? Beta-lactams are antibiotics that prevent SA (and other germs) from producing cell walls. That's generally bad news for the bacteria. (i.e. penicillin, cephalosporins, monbactams, carbapenems) Some SA have a gene, however, that allows them to form an enzyme called beta-lactamase. The enzyme destroys beta-lactams before the beta-lactams can destroy the bacterium.
Adaptation under pressure
Clinical Significance
Strategies for Prevention
Vertical Approaches Vertical approaches reduce risk of infections due to specific pathogens: Active surveillance testing to identify asymptomatic carriers Contact precautions for patients colonized or infected with specific organisms Decolonization of patients colonized or infected with specific organisms Septimus et. Al ICHE July 2014, 35; 7
Horizontal Approaches Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific: Standard precautions (i.e. hand hygiene) universal use of gloves or gloves and gowns Universal decolonization (i.e. chlorhexidine gluconate bathing) Antimicrobial stewardship Environmental cleaning and disinfection Septimus et. Al ICHE July 2014, 35; 7
What do recent guidelines say? http://www.shea-online.org/View/ArticleId/289/Compendium-of-Strategies-to-Prevent-Healthcare-Associated-Infections-in-Acute- Care-Hospitals-2014-Up.aspx • Use contact precautions for MRSA Colonized and MRSA infected individuals • Laboratory based alert system to notify hospital of admission • Provide MRSA data to key stakeholders • Educate patients and families about MRSA • Ensure cleaning and disinfection of equipment • Screen HCWs in outbreak situation • Targeted decolonization * No level 1 ( high degree of evidence)
Standard Precautions Standard Precautions Only
Targeted Prophylaxis High Risk Populations i.e. Dialysis, ICU Select Surgical Populations: JAMA June 2, 2015 Volume 313, Number 21 2165 Comparison of the matched groups revealed that implementation of the bundle was associated with reduced superficial SSIs (19.3% vs 5.7%, P < .001) and postoperative sepsis (8.5% vs 2.4%, P = .009). No significant difference was observed in deep SSIs, organ-space SSIs, wound disruption, length of stay, 30-day readmission, or variable direct costs between the matched groups Conclusions and Relevance The preventive SSI bundle was associated with a substantial reduction in SSIs after colorectal surgery. The increased costs associated with SSIs support that the bundle represents an effective approach to reduce health care costs.
Vertical vs. Horizontal
Study Group 1 implemented MRSA screening and isolation Group 2 targeted decolonization (i.e., screening, isolation, and decolonization of MRSA carriers); Group 3, universal decolonization In routine ICU practice, universal decolonization was more effective than targeted decolonization or screening and isolation in reducing rates of MRSA clinical isolates and bloodstream infection from any pathogen.
Polling Question 2 Do you place MRSA patients in contact precautions? 1. All patients infected or colonized 2. Infected patients only 3. No 4. Depends on situation and location
Discussion
MRSA bacteremia Lab ID Discuss challenges with this measure Share best practices for reducing MRSA BSI
VRE- “Not so Fearless” Enterococcus gram positive cocci in chains Human colon is a reservoir Intrinsically rugged organism Translocation across mucosa; systemic spread Biofilm
Enterococcus: Epidemiology Account for 110,000 urinary tract infections 25,000 cases of Bacteremia 40,000 wound infections 1,100 cases of endocarditis Most infections occur in hospitals Since 1989, a rapid increase of VRE
Epidemiology of VRE Risk factors for colonization/infection in USA • Severe underlying disease (malignancy, ICU, long hosp); antibiotics (vancomycin) Reservoirs, routes of dissemination not fully understood • Multiple patterns are seen in some institutions (endogenous infection from intestinal source?) • Clonal outbreaks are seen in others (transmission by HCWs?, fomites?)
VRE Screening Who should be screened? Facility-specific decision. Selectively screen newly admitted, known positives or high-risk patients Source Rectal swab or stool CDC recommendations can assist in the determination of a screening strategy – 1995 Recommendations
General Recommendations Prevention measures similar to MRSA Clearing 3 rectal swabs -1 week apart ?
Precautions Lack of consensus Contact Precautions vs. Tailored approach Endemic in organization ? Much information in the international literature
Control of VRE Conclusions: • VRE leads to many cases of colonization, few infections • Chain of infection is broken by applying standard Hygienic measures • Standard precautions and environmental hygiene • Spatial isolation for high risk groups with VRE
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